- Review and adjudicate all types of claims designated as "production claims", meeting production and quality goals.
- Review, investigate, and apply all necessary criteria to determine validity of claim.
- Understand the Anthem JAA workflow and apply JAA processing procedures, rules, and guidelines to adjudicate JAA claims.
- Apply benefit plan rules and processing guidelines to pay, pend, or deny claims.
- Manage and follow up timely on all pending claims and correspondence, including review of patient claim history.
- Prepare and generate accurate claim EOB messages and correspondence.
- Review and determine eligibility and coverage for specific group/plan.
- Research claim problems and take necessary actions to resolve.
- Utilize training and on-line documentation to keep up to date on processing guidelines, insurance principles, DOL rules and regulations, and benefit plan rules.
- Update claims system with applicable claim/and patient notes.
- Perform COB, No-fault, Pre-existing, and other claim investigations.
- Contact employers, providers, participants, as necessary.
- Identify correct providers, PPOs, and ensure that appropriate pricing is obtained.
- Perform non-complex claim adjustments, including handling of customer service referrals and take appropriate steps to initiate adjustments on JAA claims.
- Troubleshoot utilization review and medical necessity related issues utilizing AMM or other UR vendor's website information, and route claims for review accordingly.
- Utilize Claim Workflow system for work assignments, routing, and follow up.
- Handle other claim-related duties, projects, and assignments as assigned, including the handling of claim exceptions and provider not found claims.
- One to two years of college or equivalent experience.
- Minimum one years' claims experience.
- Familiarity with Eldorado Software is a plus.
- Medical billing and/or AMA coding experience preferred.
- Data Entry experience or equivalent type work using keyboard/PC.
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Medical Claims Specialist - Morristown, United States - Stafford Communications
Description
Job Title: Medical Claims Specialist - RemoteStafford Communications is uniquely different. Stafford Communications, a division of Premier BPO specializes in customer service, compliance and marketing in support of many prestigious brands in in pharmaceutical, healthcare, food, consumer packaged goods and beauty care companies - ensuring their customer service initiatives are aligned to their marketing programs.
Job Summary:
The Medical Claims Specialist is responsible for the review, investigation, decision making, and processing of production claim types, and all related claim functions and activities. Production claims are those claims under $5,000.
Essential Duties and Responsibilities:
•Knowledge of insurance and medical terminology.
•High level of keyboard/PC skills.
•Excellent oral and written communication skills.
•Good judgment and decision-making abilities.
•Good analytical and math skills.
•Good interpersonal skills and willingness to assist others.
•Basic knowledge of Word and Excel.
Pay, benefits and more:
We are eager to attract the best, so we offer competitive compensation and a generous benefits package, including full health insurance (medical, dental and vision), 401(k), life insurance, disability and more.
